A CBS Evening News story had patients calling my office today. Katie Couric reported, “A warning tonight for heart patients who combine Plavix [clopidogrel bisulfate] with heartburn drugs. Plavix is commonly prescribed to help keep arteries open, but it can also cause ulcers and internal bleeding. To prevent these complications, doctors use a drug like Prilosec (omeprazole). But according to a new study, taking the drugs together raises the risk of heart attack or death by 25 percent.” The study appears in the March 4 edition of the Journal of the American Medical Association.
According to the Wall Street Journal, the study “adds to other recent studies that suggest proton pump inhibitors (PPI) like Aciphex (raberprazole), Nexium (esomeprazole magnesium), Prevacid (lansoprazole), and Protonix (pantoprazole sodium) reduce the effectiveness of Plavix.”
For the study, researchers looked “at more than 8,000 patients discharged from 127 Veterans Affairs hospitals between October 2003 and January 2006” and found that “patients taking a combination of Plavix and a PPI had ‘an increased risk of adverse outcomes’ compared to those taking Plavix alone.”
In fact, Bloomberg News notes, “About 30 percent of patients taking the stomach medicines, known as proton pump inhibitors, died or were readmitted, compared with 21 percent of those given only Plavix.”
The study also “found that most additional deaths and hospitalizations were from acute coronary syndrome, a group of heart conditions Plavix is prescribed to prevent.”
Lead researcher Dr. P. Michael Ho, a cardiologist at the Denver VA Medical Center, told HealthDay, “A lot of patients are on Plavix and also a lot of patients are being prescribed PPI medication just prophylactically to prevent a stomach bleed.” He said that the “study doesn’t change the reasons for prescribing Plavix,” but he added that “both clinicians and patients should look at why the PPI is being prescribed. It shouldn’t be prescribed prophylactically just to prevent a GI bleed, because there might be an interaction between the PPI and Plavix.”
Dr. Ho said a PPI “should only be prescribed to patients who have had a stomach bleed, since they are at higher risk of another bleed.”
However, WebMD added that “findings from a large Canadian trial, reported in late January, suggest that all PPIs are not equal when it comes to inhibiting the antiplatelet activity of Plavix.”
In that study, according to study researcher David N. Juurlink, MD, PhD, “although most PPIs did appear to interact with Plavix, one — Protonix (pantoprazole) — showed no evidence of reducing the effectiveness of the antiplatelet drug.”
So, what should you do if your doctor has prescribed Plavix and a PPI for you? First of all, DO NOT STOP EITHER MEDICINE. Second, call your doctor’s nurse in the next few days to discuss whether you should make an appointment to discuss this with your doctor.
Understand that treatment with stents requires use of dual antiplatelet therapy with Plavix (clopidogrel) plus aspirin, which can increase the risk of gastrointestinal bleeding. For such patients proton pump inhibitors may be prescribed to reduce the bleeding risk, but that this study finds that doing so may not be a good idea.
One possible exception may be the proton pump inhibitor, Protonix (pantoprazole). So, your doctor may want to either change you to Protonix or to an H-2 inhibitor (such as cimetidine, famotidine, nizatidine, or ranitidine).